Stop Using Antidepressants Except for “the Most Severe Depression,” Experts Say

In a new article in the British Medical Journal (BMJ), 30+ prominent figures in critical psychiatry call on the UK government to acknowledge the evidence that antidepressants are no better than placebos for most patients and to increase funding of social and psychological interventions while decreasing drug prescriptions.

“Multiple meta-analyses have shown antidepressants to have no clinically meaningful benefit beyond placebo for all patients but those with the most severe depression,” they write.

The 30-plus list of authors reads as a veritable “who’s who” of names in critical psychiatry. The lead author was James Davies, co-founder of the Council for Evidence-Based Psychiatry (CEP), senior lecturer in social anthropology and psychotherapy at the University of Roehampton, and practicing psychotherapist in the UK. The second author was John Read, chair of the International Institute for Psychiatric Drug Withdrawal, professor of clinical psychology at the University of East London, editor of the journal Psychosis, and expert on ECT and psychosis.

Other prominent authors include Joanna Moncrieff (professor of critical and social psychiatry at University College London and founder of the Critical Psychiatry Network) and Mark Horowitz (clinical research fellow in psychiatry at North East London NHS Foundation Trust), whose 2022 paper put the final nail in the coffin of the serotonin theory of depression; Lucy Johnstone, a clinical psychologist who helped launch the Power Threat Meaning Framework, a non-diagnostic alternative to the DSM; Jo Watson, a psychotherapist who founded Drop the Disorder; psychologist Peter Kinderman; Luke Montagu, who joined Davies to co-found the CEP; and Sam Everington, who was knighted and received the OBE for his work in improving primary care. The article also featured psychiatrists, general practitioners, members of parliament, and advocates with lived experience.

“We, a group of medical professionals, researchers, patient representatives, and politicians, call for the UK government to commit to a reversal in the rate of prescribing of antidepressants,” they write.

We Must Reduce Antidepressant Use

Clinical practice guidelines outside the US, such as the NICE guidelines in the UK, already suggest that antidepressants are not the best first-line intervention for mild to moderate depression. The NICE guidelines suggest watchful waiting, guided self-help, various psychotherapies, exercise, and mindfulness/meditation as better options for less severe depression since they have equal effectiveness but much lower risk of adverse effects. Take, for instance, a recent meta-analysis finding that exercise is just as good as antidepressants at treating mild to moderate depression—and that adding drugs to the regimen does not improve outcomes.

The World Health Organization (WHO) guidelines on depression treatment are even more firm: “Antidepressant medications are not needed for mild depression,” according to the WHO.

Even for severe depression, multiple studies have found that adding antidepressants to cognitive behavioral therapy does not result in better outcomes—psychotherapy alone is just as good in the short term. And therapy alone beats the drugs when it comes to long-term outcomes.

Moreover, psychotherapy doesn’t have the harmful effects of antidepressant drugs, which include sexual dysfunction for up to 88% of those taking them, weight gain and metabolic problems, emotional numbing, and more. Likewise, withdrawal is common after someone stops taking antidepressants and can be severe and last for years. Withdrawal effects of the drugs can include anxiety, depression, brain zaps, fatigue, and even stroke-like symptoms.

Nonetheless, prescriptions for the drugs keep rising. Davies and his co-authors note that antidepressant prescription rates have nearly doubled in the UK over the past decade.

Yet, the authors write, “Rising antidepressant prescribing is not associated with an improvement in mental health outcomes at the population level, which, according to some measures, have worsened as antidepressant prescribing has risen.”

Most people still receive a pill if they present with mild depression—or even undiagnosable, vague malaise. One study in the US found that only 2% of those taking antidepressants actually had severe depression—with more than half failing to meet the criteria for depression. Similarly, a UK study found that more than half of the people on antidepressants don’t meet the criteria for any psychiatric diagnosis. A 2015 study found that more than two-thirds (69%) of those prescribed an antidepressant do not meet the criteria for the diagnosis of depression.

Davies and his co-authors add that the people who disproportionately receive antidepressants are those living in impoverished areas, women, and the elderly—raising questions, they write, “about the extent to which we are wrongly medicalizing and medicating the effects of disadvantage and deprivation.”

The authors write that the prescription of antidepressants for mild depression and non-psychiatric distress must stop. Also, centers focused on withdrawal must be funded to help people struggling to discontinue the drugs. Finally, funding should be diverted to social prescribing, which focuses on the isolation, poverty, and marginalization most associated with the symptoms of depression and which is supported by the WHO.

As James Davies said in a speech to the UK Parliament:

“Pills can’t save broken marriages; they can’t erase a painful past or build community. They can’t bring a loved one back. They can’t solve poverty or poor housing, or right the wrongs of inequality or discrimination, or resolve any other well-evidenced social determinant of poor health. They are what they are; they have their place. But they also need to stay in their place.”

Is There Evidence for Antidepressant Efficacy?

Countless studies have challenged the efficacy of antidepressant drugs for decades. One analysis in 2010 found that the benefit of antidepressant medications “may be minimal or nonexistent, on average, in patients with mild or moderate symptoms”; this leaves open the possibility that for severe depression, the drugs do provide a benefit, however.

Yet researchers in 2008 found that although antidepressants appear slightly more efficacious for severe depression, the difference is “relatively small even for severely depressed patients.” The researchers go on to state that this benefit is attributable to the placebo effect becoming less powerful for patients with severe depression rather than an increase in the efficacy of the drug.

Worse, in another study, researchers found that those with more severe depression, those with comorbid anxiety, and those who were suicidal were least likely to benefit from the drugs.

The drugs are known to make people feel suicidal rather than protect against suicide: A recent study found that antidepressants increased suicidality threefold in children and adolescents and doubled the risk in those 18-24, and didn’t reduce suicidality even for older patients.

That’s consistent with previous studies, which have repeatedly shown that antidepressants increase suicide risk, particularly for children and adolescents, with some studies finding more than doubling the risk of suicide and at least one analysis finding a sixfold increase.

Since the 1990s, researchers have warned of the danger that antidepressant treatment worsens outcomes by disrupting the brain’s natural functioning. These warnings have been borne out in multiple studies: Researchers have indeed repeatedly found that those taking the drugs have worse outcomes in the long term, even after controlling for the baseline level of depression severity.

And even all these negative findings and warnings can be considered optimistic because of publication bias—negative studies are much less likely to be published. For instance, a study in the New England Journal of Medicine in 2008 examined both published and unpublished studies of antidepressant efficacy. They found that half of the antidepressant trials found no beneficial effect for antidepressants compared with placebo. The only problem: almost none of the negative studies were ever published, and those that were ended up “spun” to appear positive.

But depression—in its natural state—is self-limiting. If you don’t receive treatment, you are actually quite likely to recover on your own. An NIMH study in 2006 found that 85% of untreated depressed patients recovered spontaneously within one year.

Compare that to outcomes for treated depression: in a study where over a thousand people with depression were treated with an intense program, beginning with antidepressant drugs (more than half on multiple drugs) and also including psychotherapy and hospitalization, less than 25% even responded to treatment, much less recovered. Unfortunately, this study had no placebo group to which we could compare this effect, but in clinical trials, the placebo effect averages about 31%—meaning that more people would be expected to benefit from a placebo than benefited from aggressive drug treatment in the study.

 

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Davies, J., Read, J., Kruger, D., Crisp, N., Lamb, N., Dixon, M., . . . & Marshall-Andrews, M. (2023). Reversing the rate of antidepressant prescribing: Politicians, experts, and patient representatives call for the UK government to reverse the rate of antidepressant prescribing. BMJ, 383, 2730. doi: (Link)

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